MEDICARE: MIDWEST MOBILE DIAGNOSTICS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246Z00000X	Other Specialist/Technologist

General Provider Information

NPI Number	:	1164761649
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST MOBILE DIAGNOSTICS LLC

Provider Business Mailing Address
First Line	:	175 N HARBOR DR
Second Line	:	SUITE 2111
City	:	CHICAGO
State	:	IL
Zip	:	60601-7344
Country	:	US
Telephone Number	:	312-502-2286
Fax Number	:

Provider Business Practice Location Address
First Line	:	175 N HARBOR DR
Second Line	:	SUITE 2111
City	:	CHICAGO
State	:	IL
Zip	:	60601-7344
Country	:	US
Telephone Number	:	312-502-2286
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. KAREN M WRAY
Credential	:	RDMS, RVT
Telephone Number	:	312-502-2286

Provider Enumeration Date	:	02/04/2013
Last Update Date	:	02/04/2013

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